Download Impact of migration on infectious diseases in Europe

statement
European Academies
Science Advisory
Council
For further information
Fiona Steiger
EASAC Secretariat
The Royal Society
6–9 Carlton House Terrace
London, SW1Y 5AG
Tel: +44 (0)20 7451 2697
Fax: +44 (0)20 7925 2620
[email protected]
Impact of migration
on infectious diseases
in Europe
Summary
Most migrants to the EU are healthy but in population terms may bear a
disproportionate burden of infectious disease. Communicable diseases will vary
in the extent to which a migrant might be infected before entry to the EU (for
example, HIV/AIDS) or afterwards, within the Member State and linked to
vulnerable socio-economic status (for example, tuberculosis (TB)). Comprehensive
data on infectious disease burdens of migrants are currently lacking.
The public health implications of migration have received comparatively little
attention in EU policy development, but it is important not to generalise about
migrants or infectious disease. The approach to screening and management is
likely to differ for those diseases that spread relatively slowly (TB, HIV) from those
that may pose an acute threat (for example, severe acute respiratory syndrome
(SARS)). Detection of disease on screening must not be used as a reason to deny
entry to the EU, for that would deter migrants coming to screening and the
identification of high-risk patients. Migrants need to be offered the same access
to healthcare services as the rest of the population. It is also important for
Member States to do more in tackling infectious disease in developing countries
in order to reduce the global burden of disease.
Among the key challenges for healthcare systems are:
• Improving evaluation and sharing of information on current screening practices
across the EU.
• Facilitating healthcare access and improving healthcare follow-up of migrants
after the initial contact, as part of a general need to enhance primary care
services in some Member States.
• Developing information and communication systems to improve awareness
and support interaction between patients and the healthcare system.
• Co-ordinating strategies for screening and follow-up practices for high-risk
groups across the EU.
• Developing consensus on those infectious diseases most relevant to migration.
• Progressing research to clarify issues where currently there is uncertainty. In
particular, well-designed research studies are needed to determine: (i) burden
of infectious disease in migrant groups; (ii) nature of health inequalities –
including vaccination status – between migrants and the rest of the
population; (iii) nature and degree of net public health risk attributable to
migration; (iv) efficacy of alternative screening approaches – it is essential to do
better in assessing the benefits of screening and to include the evaluation of
approaches based on surveillance and sentinel systems in the strategic analysis
of the options for managing infectious disease-related migration problems.
In summary, the priorities for research and policy development require improved
collection of epidemiological data, increased sharing and implementation of
good practice in screening systems, and establishment of mechanisms for access
to healthcare. We recommend further discussion, as part of the Portuguese EU
Council Presidency priority theme, with the goal of devising a standardised set of
protocols for testing and healthcare provision.
Impact of migration on infectious diseases in Europe
| August 2007 | 1
Introduction
1
Previous work by EASAC , in reviewing strategic
scientific issues in combating infectious disease, has
examined European priorities for public health and
innovation associated with disease surveillance and
control, infrastructure and skills, and support for
research and development of novel products and
services. Each of the three EASAC reports has noted
that there are issues for public health associated
with increasing levels of international travel. As the
Vaccines Report (2006) noted, ‘… the increasing
internal movement of goods and people encourages
the spread of infection.’
The effects of globalisation in exacerbating the risk
of spreading infectious diseases (Weiss and
McMichael, 2004)2 are mediated not only through
the movement of people but also by the increased
mobility of disease vectors, livestock and other
animals that may host zoonoses, as well as the
greater propensity for food-borne disease in
consequence of increasing legal and illegal trade.
health and migration in order to develop effective
health policies and strategic programmes for migration.
Migrants are a very diverse group in terms of their
reasons for migration and their country of origin.
Many are students or holders of work permits; a much
smaller number are asylum seekers. For the present
purpose, we consider migration in terms of crossing
the borders of the EU rather than from one Member
State to another, except where that represents
onward movement of a migrant arrived in the EU.
Comprehensive discussion of some of the general
issues for migration and health in the EU is provided
in the background reports commissioned by the
Presidency conference organisers.
It is not the purpose of the present paper to
recommend specific screening programmes but
rather to identify what further information is needed
in order to be able to make decisions on screening
and management.
Global background
The objective of the present, short EASAC paper is
to concentrate on those scientific issues relating to
infectious disease and public health that may be
associated with the movement of people across the
borders of the EU, with particular reference to
migration. There are many reasons for travel across EU
borders, including tourism, business and pilgrimage,
but these are outside the scope of the present
discussion. This paper focuses on migration in order
to serve as an input to the forthcoming Portuguese
Presidency of the European Council priority theme of
‘Migration and Health’. A Portuguese Presidency
conference ‘Health and migration in the EU: better
health for all in an inclusive society’ will provide
demographic analysis of migratory flows in the EU,
analysis of health challenges and determinants of
migration, a review of Member State health policies
and evaluation of the impact of these policies.
• According to the US National Intelligence Council
study (2000)3 of factors affecting the spread of
global infectious disease, two million people each
day travel across borders, including one million
each week between developing and developed
countries. The US Institute of Medicine (2006)4
observed that over the past two centuries, the
average distance and speed of human travel have
increased a thousand-fold but incubation times for
infectious diseases have remained the same: ‘No
nation is immune to the growing global threat
that can be posed by an isolated outbreak of
infectious disease in a seemingly remote part of
the world.’ Previous EASAC reports have
documented the potential risk for EU countries
from the global spread of infection, exemplified by
the threat from SARS (EASAC, 2005) and H5N1
pandemic influenza (EASAC, 2006).
The Presidency’s aim is to promote debate and
understanding about the connections between
• The joint Science Academies G8 statement on
infectious disease (2006)5 called for reinforcement
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2
3
4
5
EASAC (2005) Infectious diseases – importance of co-ordinated activity in Europe; EASAC (2006) Vaccines: innovation and human
health; EASAC (2007) Tackling antibacterial resistance in Europe.
Weiss, R.A. and McMichael, A.J. (2004) Social and environmental risk factors in the emergence of infectious diseases. Nature Medicine
10, S70–S76.
National Intelligence Council USA (2000) The global infectious disease threat and its implications for the United States, at
www.dni.gov/nic/ special_globalinfectious.html.
Institute of Medicine (2006) The impact of globalization on infectious disease emergence and control.
Joint Science Academies (2006) Avian influenza and infectious disease, accessed via The Royal Society website at www.royalsoc.ac.uk/
document.asp?tip=0&id=4823.
2 | August 2007 | Impact of migration on infectious diseases in Europe
of global surveillance as the fundamental instrument
for control of infectious disease, indicating that a
new, independent, evidence-based study is needed
to identify key elements for the further
development of global surveillance capabilities.
• A recent UN High-level Dialogue on International
Migration and Development6 noted that migration
now accounts for 75% of population growth in
developed countries. In 2004, in the EU-15, net
documented migration was 1.8 million in a total
population of 460 million.
• With regard to undocumented (illegal) migration,
an estimated 400,000 people cross EU borders each
year without the necessary travel documents7.
The EU Hague Programme on Justice, Freedom
and Security sets out an agenda to fight illegal
migration and recent Council Presidencies have
prioritised further development of shared European
responsibilities on border controls. The public
health implications of migration have received
comparatively less attention at the political level.
It might be supposed that tighter border controls
would help the control of movement and the
tracking of people entering the EU. However,
tighter border controls may also increase
trafficking and worsen the conditions of migration
and settlement, in particular for access to care.
In this sense, the Hague Programme might have
unintended and deleterious consequences for
migrants’ health.
Migration and infectious diseases: analysis
of the evidence
A recent report on the situation in the UK (Health
Protection Agency, 2006)8 noted that most migrants
are healthy young adults but in population terms
bear a disproportionate burden of infectious disease;
approximately 70% of newly diagnosed cases for
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8
9
10
11
12
13
each of the diseases TB, HIV and malaria were in
patients born outside the UK.
A recent press release from the European Society for
Clinical Microbiology and Infectious Diseases
(ESCMID)9 observed that TB represents an emerging
epidemic in many large European cities (for example
in Spain and Greece) as it is strongly related to
increasing migration from Asia, Africa and Latin
America. Many of the migrants develop the infection
in consequence of their socio-economic status in the
host countries10. ESCMID also noted both the
vulnerability of the EU to the re-introduction of
malaria during migration because of re-colonisation
by Anopheles mosquitoes of their previous habitats
in the Balkans, and potential health issues related to
migration from Latin America, for example Dengue
fever in Spain. Further consideration of these
infectious disease challenges will also need to take
account of the potential influence of climate change
that may encourage vector populations for diseases
previously eradicated in European countries (for
example malaria, leishmaniasis) or not previously
present in Europe (for example, Dengue fever). Thus,
in considering the broader issues for the spread of
infectious disease in Europe, it is essential to take
account of changes in vector migration as well as
human migration: these issues will be discussed in
further detail in a forthcoming EASAC report on
zoonotic infections.
Evidence presented at a conference organised by the
Federation of European Academies of Medicine in
200611 described problems for Portugal (migrants
from Latin America and Africa have comparatively
high rates of HIV and TB), Hungary (HIV as a
problem for migrants from neighbouring countries),
Greece (migrants from East Africa bear a substantial
proportion of the HIV burden) and France (migrants
with TB)12 An editorial in The Lancet (2006)13
September 2006: www.un.org/esa/population/hldmigration/.
‘Countries try to get to grips with recent immigration crisis’ 25 July 2006, www.euractiv.com.
Health Protection Agency (2006) Migrant Health. Infectious diseases in non-UK born populations in England, Wales and Northern
Ireland. At www.hpa.org.uk/publications/2006/migrant_health/default.htm.
ESCMID press release 31 March 2007, www.escmid.org/sites/index_f.aspx?par=3.6.
As TB is traditionally associated with poverty, the living conditions in the country of origin explain part of the high prevalence, related
to poor housing, nutrition and access to care. However, conditions in the host country may also play a role as migrants often
experience deprivation through exclusion and poverty (Ponticiello, A., Sturkenboom, M.C., Simonetti, A., Ortolani, R., Malerba, M.
and Sanduzzi, A. (2005) Deprivation, immigration and tuberculosis incidence in Naples, 1996–2000. European Journal of
Epidemiology 20, 729–734).
Conference, November 2006 ‘Vaccination against infectious diseases, animal and human’. Slide sets at www.feam.eu.com for
Hungary, Portugal and France.
Evidence collected in France by the Agence Nationale de l’Accueil et des Migrations (ANAEM) shows that the prevalence of TB in
migrants was approximately 20-fold greater than the French overall prevalence.
Anon. (2006) Migration and health: a complex relation. The Lancet 368, 1039.
Impact of migration on infectious diseases in Europe
| August 2007 | 3
concluded that the most pressing health problem for
migrants is increased vulnerability to communicable
diseases, perhaps particularly HIV/AIDS. In aggregate,
in 2005, approximately one quarter of those
diagnosed with HIV in the EU were non-EU citizens
(mostly from sub-Saharan Africa) and most of them
are believed to have been infected in their country
of origin14.
could spread rapidly and may pose acute threats to
healthcare systems (for example, SARS, smallpox,
Ebola fever) will differ from the chronic communicable
diseases such as HIV and TB. However, the public
health issues for the category of acute diseases are
not specific for migrants and should be considered
within the broader context of travel medicine.
The implications of screening
The initial conclusion reached by the Working Group
on reviewing the evidence is that significantly more
research is needed to quantify the situation in
different Member States and to account for apparent
differences in the prevalence data for the major
communicable disease threats. The experience of the
Working Group members also indicates that there
may be additional, newly emerging pathogens related
to human transcontinental migration. For example,
there is an increasing problem of Taenia solium
neurocysticercosis occurring in the USA, which may
also become a problem for Europe, Entamoeba
histolytica amoebiasis has established autochtony
(cycles of transmission) in some European countries
and leishmaniasis is increasing in prevalence in the
more northern regions of Europe. Antimicrobialresistant micro-organisms are also not only a local
problem: they can spread rapidly throughout the
world in humans, animals, vectors and food.
Growing drug resistance is becoming a particular
problem for TB. As discussed in the recent EASAC
report on Antibacterial Resistance (EASAC, 2007),
it is expected that levels of resistance will change
according to the pattern of migration and other
movement.
These examples are illustrative and, although
comprehensive data are lacking, it can be concluded
that where a study has been made, problems have
been found. There is urgent need for more research
to collect data and for more evaluation of the research
output to determine the quality of the data already
available in the absence of conventional peer review
or other formal quality assessment. It is important
not to generalise about migrants or infectious
diseases. The implications for screening and
management of certain infectious diseases that
14
15
There is relatively little evidence to show that
screening by Member States is useful, but that is
mainly because there have been few attempts to
collect the evidence. Where migrant screening
programmes are available, for example for TB, there
is some evidence that tests are not always sensitive
(missing cases) or applied consistently (for example,
only on first entry, not on return to the EU after a
visit to the country of origin). In the particular
example of TB, tuberculin skin testing as a method
for screening migrants is unreliable, and alternative
approaches have not yet been well validated for
screening.
The Working Group observed that pre-departure
screening (in the country of origin) is not generally
efficient or effective and may not indicate disease
status on arrival in the EU. Moreover, this approach
may be discriminatory and encourage illegal
migration. A recent editorial in the journal Lancet
Infectious Diseases15 provides a good critique of the
problems created by those countries requiring predeparture screening with denial of entry to migrants
who test positive for HIV or TB: ‘It is imperative that
public-health policies in relation to migrants are
based on rational arguments and a sound evidencebase, not political agendas.’
Most migrants are healthy and, in the consensus
view of the Working Group, detection of disease at
screening on arrival in the host country must also
not be used as a reason to deny entry to the EU.
Migrants identified as having a transmissible disease
must have full access to medical treatment and be
accessible to public health measures (such as contact
tracing), not only for ethical reasons but also
because public health measures to prevent further
Hamers, F.F., Devaux, I., Alix, J. and Nardone, A. (2006) HIV/AIDS in Europe: trends and EU wide priorities. Eurosurveillance at
www.eurosurveillance.org/ew/2006/061123.asp. The evidence from France, consistent with this aggregated HIV analysis, shows also
that (i) most of this group are female, and (ii) the proportion of newly diagnosed HIV-positive cases from sub-Saharan Africa has
perhaps decreased during the past two years.
Anon. (2007) Old habits die hard. Lancet Infectious Diseases 7, 369.
4 | August 2007 | Impact of migration on infectious diseases in Europe
spread of disease cannot otherwise be enacted.
Denying entry to the EU because of detected
infections will not prevent, but rather propagate, the
spread of disease because infected migrants might
become inaccessible to the public health service but
still remain in contact with susceptible populations
within the EU. The political issues for rationing
healthcare resources are beyond the scope of this
paper.
What are the key issues for healthcare systems?
• There is need to do more to evaluate and share
the information available on current practices in
European countries, identifying good practice to
implement more broadly. For example, in Italy,
screening for communicable disease is not
mandatory but offered as part of migrant access
to the healthcare system and in association with
national attempts to inform migrant communities
on what care is available. Working Group
discussion of experience in other European
countries (for example, Portugal, Greece, the
Netherlands, France, UK, Sweden and Switzerland)
highlighted the various approaches to providing
free healthcare for communicable diseases.
• There is difficulty in ensuring healthcare follow-up
of migrants after the initial contact. However, the
challenge of follow-up and provision of
appropriate treatment is not confined to migrants,
and there is a general case to be made to improve
primary care in some Member States. It is crucial
to understand better the barriers in access to care
among migrant populations, including the reasons
for lower adherence to treatment and difficulties
in follow-up. Information and communication
systems are needed at the primary-care level to
create awareness and support interaction between
patients and healthcare professionals.
• There is need to distinguish between infectious
diseases in considering the policy options,
although this is complicated by the challenge of
co-infection. TB is commonly screened by Member
States but HIV/AIDS is not, and some tropical
diseases that were previously screened are not
now, despite their recurrence. It would be valuable
to compile a database of those infectious diseases
most relevant to migration and travel medicine
generally, including the (re-)emerging diseases
where there is risk of re-initiating cycles of
transmission in European countries.
• Communicable diseases will vary in the extent to
which a migrant is infected before entry to the EU
or afterwards. For those two infectious diseases
that are of the greatest importance for migration, as
noted previously, TB infection is judged frequently
to occur within the Member State and is linked to
vulnerable socio-economic status whereas
HIV/AIDS may present the greater problem in some
countries of origin. More research is required to
document and elucidate these epidemiological
differences in order to examine the potential social
determinants of disease. There is also very little
information on the extent to which the host
population is at risk from infection by migrants –
the risk is assumed to be low but there is need for
better research studies, for example by typing
pathogen strains and characterising antibiotic
resistance patterns.
• It is important to co-ordinate screening and followup practices for high-risk groups across the EU. In
addition to screening, additional tools are needed,
including surveillance and sentinel systems,
depending on the infectious agent. Before policy
options can be fully informed, there are some
major areas of scientific uncertainty to resolve in
terms of the impact of infectious disease on
migrants, the secondary impact on their contacts
and public health systems and the cost–benefits of
screening and treatment. The evidence cannot be
derived from case reports alone because of the
lack of denominator – there is need for welldesigned research to define risk, and track trends –
but even in the absence of definitive studies there
is value in doing more to collect narrative data
more systematically. An improved evidence base
would be highly useful to counter ‘media scare
stories’ as well as to inform the future policy
decisions on screening strategies (for example,
deciding the relative merits of risk-based or wholepopulation approaches). There is, of course, a
particular challenge in ascertaining the health status
of undocumented migrants, and the research
community must consider further the appropriate
research tools.
Impact of migration on infectious diseases in Europe
| August 2007 | 5
Conclusions and recommendations
Relevance of health to consideration of EU
migration strategy We conclude that the
public health implications of communicable disease
are very important elements for development of the
broader strategy to manage migration issues for the
EU. We agree with the organisers of the Portuguese
Presidency conference that the priorities for further
research and policy development cover:
1
(i) improved collection of information;
(ii) assessing, sharing and implementing best
practice in screening;
(iii) establishing mechanisms of access to healthcare.
Clarifying what is known/not known and
filling information gaps The European
Commission and Member States need to collect
better statistics to quantify the impact of migration
on health and health systems – partly by building on
current EU and international (World Health
Organization) efforts and partly by supporting new
joint initiatives with neighbouring and developing
countries for fact-finding and interpretation. In
particular, additional validated data are required to
determine:
2
(i) burdens of infectious disease in migrants;
(ii) nature of health inequalities between migrants
and other groups in the population;
(iii) nature and degree of public health risk
attributable to migration;
(iv) efficacy of screening and alternative approaches,
including surveillance and sentinel systems;
(v) vaccination status of migrants – to establish
healthcare system priorities to assure access to
immunisation schedules;
(vi) modelling of disease transmission to estimate
public health impacts, what is an effective
intervention and what is cost-effective;
(vii) barriers in access to treatment and follow-up.
Screening, surveillance and treatment
strategies The efficacy of screening depends
on disease prevalence, available test methods, their
sensitivity and predictive value, and the provision of
healthcare measures to respond to the test result.
It is essential to do better in assessing the efficacy
of screening programmes. And it is of the greatest
importance to use the new knowledge collected to
inform systematic evaluation of the facilities and
procedures available to migrants at their point of
entry to the EU. Currently, it must be assumed that
many cases of infectious disease are missed at this
early contact stage and there is need to share the
examples of good practice in Member States for
reception centres and initial presentation to the
healthcare system.
3
We recommend that the agenda of the Portuguese
Presidency discussions should include this review of
good practice with a goal of devising a standardised
set of protocols for testing and healthcare provision,
which can be implemented according to local
circumstances. Standardisation of practice in
screening and care approaches would also provide
the basis for collecting better data to inform future
policy choices. Efforts to standardise at the European
level will be dependent on good networking
between Member States and must be augmented by
support for training locally and by improved provision
of information to communities of migrant patients.
The European Centre for Disease Prevention and
Control (ECDC) must continue to develop its key role
in EU-wide surveillance of current and emerging
infections, and in co-ordination to ensure that
Member State authorities provide standardised and
detailed surveillance statistics in compiling the
evidence base. We welcome the current ECDC
activity, in response to a request for guidance from
the European Commission, on evaluation of the
options for migrant access to HIV prevention and
care. We agree that it is necessary to explore a wide
range of issues in this evaluation, covering social
integration (relating to stigma, socio-economic and
legal status), epidemiology (transmission and risk
factors), surveillance (definition of high risk groups)
and the barriers to accessing prevention and care
services (at institutional, provider and client level).
6 | August 2007 | Impact of migration on infectious diseases in Europe
Global co-ordination The EU must take a
leadership role in strengthening public health
capacity in newer Member States and in developing
countries. The European Commission and Member
States must also continue to explore how they can
help implement the recommendations from the joint
Science Academies Statement on Infectious Disease
(2006)16. Not only must Member States assist in the
cost of diagnosis and treatment for migrants under
the provisions available to EU citizens, it is also
important for Member States to tackle infectious
disease in developing countries in order to reduce
the global burden of disease.
4
Gerard Krause, Robert Koch Institute, Berlin,
Germany
Miriam Lichtner, Department of Infectious and
Tropical Disease, La Sapienza University, Rome, Italy
Angela McLean, Department of Zoology, University
of Oxford, UK
Mihai Netea, Department of General Internal
Medicine, Radboud University Nijmegen, the
Netherlands
Julian Perelman, National School of Public Health,
New University of Lisbon, Portugal
Gianluca Russo, Department of Infectious and
Tropical Disease, La Sapienza University, Rome, Italy
Appendix: Expert consultation
This paper was prepared by consultation with a
group of experts, acting in an individual capacity,
and was reviewed and approved by EASAC Council.
We are grateful to all who contributed to the
Working Group:
George Saroglou, Department of Internal Medicine,
University of Athens, Greece
Alain-Jacques Valleron, INSERM, Hospital Saint
Antoine, Paris, France
Robin Fears (secretariat), EASAC, UK
Volker ter Meulen (Chairman), President of the
German Academy of Sciences Leopoldina,
Germany
Ana Fernandes, National School of Public Health,
New University of Lisbon, Portugal
A draft of the Working Group output was discussed
with Francoise Hamers (ECDC) and Robin Weiss
(University College London, UK): we are also grateful
for their review.
Bruno Gottstein, Institute of Parasitology, Vetsuisse
Faculty and Faculty of Medicine, University of
Berne, Switzerland
16
See footnote 5 for citation of the Joint Science Academies statement. The issues for global co-ordination have also been discussed in
previous EASAC reports, particularly 2005, 2006 (see footnote 1).
Impact of migration on infectious diseases in Europe
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EASAC
EASAC – the European Academies Science Advisory Council – is formed by the national science academies of
the EU Member States to enable them to collaborate with each other in providing advice to European policymakers. It thus provides a means for the collective voice of European science to be heard.
Its mission reflects the view of academies that science is central to many aspects of modern life and that an
appreciation of the scientific dimension is a pre-requisite to wise policy-making. This view already underpins
the work of many academies at national level. With the growing importance of the European Union as an
arena for policy, academies recognise that the scope of their advisory functions needs to extend beyond the
national to cover also the European level. Here it is often the case that a trans-European grouping can be
more effective than a body from a single country. The academies of Europe have therefore formed EASAC
so that they can speak with a common voice with the goal of building science into policy at EU level.
Through EASAC, the academies work together to provide independent, expert, evidence-based advice about
the scientific aspects of public policy to those who make or influence policy within the European institutions.
Drawing on the memberships and networks of the academies, EASAC accesses the best of European science
in carrying out its work. Its views are vigorously independent of commercial or political bias, and it is open
and transparent in its processes. EASAC aims to deliver advice that is comprehensible, relevant and timely.
EASAC covers all scientific and technical disciplines, and its experts are drawn from all the countries of the
European Union. It is funded by the member academies and by contracts with interested bodies. The expert
members of project groups give their time free of charge.
EASAC’s activities include substantive studies of the scientific aspects of policy issues, reviews and advice
about policy documents, workshops aimed at identifying current scientific thinking about major policy issues
or at briefing policy-makers, and short, timely statements on topical subjects.
The EASAC Council has 25 individual members – highly experienced scientists nominated one each by the
memberr national science academies, the Academia Europaea and ALLEA. It is supported by a professional
secretariat based at the Royal Society in London. The Council agrees the initiation of projects, appoints
members of project groups, reviews drafts and approves reports for publication.
For further information
Fiona Steiger, EASAC Secretariat
The Royal Society, 6–9 Carlton House Terrace, London, SW1Y 5AG
Tel: +44 (0)20 7451 2697 | Fax: +44 (0)20 7925 2620 | email: [email protected]